So much has happened in the world of Wellthcare I don’t know where to start. I’m a reductionist at heart so let’s start with a number – 20. This is the percentage that health care contributes to our health, according to Nancy Adler of the University of California, San Francisco. She was writing for ‘Investing in what works for American communities’, a project that calls on leaders from the public, private, and non-profit sectors to build on what we know is working to move the needle on poverty. It’s worth taking a moment to reflect on that number. It’s small. And yet when you read about health, whether it’s in the mainstream media, academic journals or the effervescent health innovation scene, what you’re really reading about is health care. It’s very rare to read about health creation. I’m saying this a lot these days and am always countered with the idea of prevention. There are two reasons why I am reserved about prevention.

First of all it’s a sort-of time-delayed conversation about health care masquerading as a conversation about health. Sure, the idea is to generate health but it’s predicated – and financially modelled – on reducing the likelihood of specific diseases, hence reducing the demand for health care. For me, despite appearances to the contrary, this locks it in the 20% space – health care not health creation. The second reason why I am reserved about prevention is that it simply does not work – or at least does not work well enough, especially in the communities that need it most. While we know what people need to do to prevent disease we don’t know how to make them do it sustainably (indeed, the very idea of making people do something may be the core of the problem). Consequently what we’re seeing is that prevention – or wellness programmes – are a waste of money; for every $1 invested the return appears to be $0.48, and even that is considered an over-estimate. So health care and prevention contribute only 20% to our health and the latter doesn’t even work. Now what? The 80% that contributes to our health comes from our genes, our behaviours, social factors and the environment. We hear a lot about these topics and yet – if you really think about what you’re hearing – it’s largely based on reducing the cost of care. We’re using the value model we’ve developed for health care to assess the worthiness of the 80%. That makes no sense. Isn’t it time we found a new model or models? The investor, Esther Dyson, has recently written about this.

Producing health connotes an activity, not a state. You cannot simply avoid disease; you have to do something to promote creation of the desired capacity… Players in the health-production business include not just companies and employers, but also national and local governments, health systems, schools, and buildings. All of them have a long-term interest in the health of the people they serve…

However, she goes on to say:

Yet I confess to doubt. Getting the language right is easy compared to actually delivering on the promise.

My view is that the doubt hinges on the fact that we don’t yet have models to value health creation. The most inspiring I have seen to date remains this sketchy video by David Relph, the Head of Strategy and Business Planning at University Hospitals Bristol, in which he suggests using social impact bonds. There’s something deeply authentic about David’s work – it’s scrappy, exploratory, not slick. It feels like the visual manifestation of the uncertainty and ambiguity in which we have to find new forms of health-related value.

We have to start experimenting in the 80% - and we have to accept that we don’t know what we’ll find. We have to pool what we learn to slowly start building the value model or models. At Wellthcare we believe that new forms of health-related value sits in our networks and communities, and are defined by what people want to achieve in their lives. By nature, this means it’s complex, making the potential value emergent – in essence, unpredictable. We realise this is an issue for investors but we need to find ways to release money for careful but courageous experimentation in health creation. Although it may feel overwhelming there are two movements out there that give me hope. The Democracy Collaborative is doing sterling work linking the operations of ‘anchor institutions’ – major local employers – to better outcomes for local communities. They’ve come up with a number of indicators to guide people, all of which are based on analysing case studies. In the US, hospitals are often anchor institutions so it’s an interesting question to ask how they create community value above and beyond dealing with sickness (how many hospitals do you know are asking themselves that question?). The second movement is collective impact, the idea that a group of actors from different sectors can join forces to solve a complex social problem. In a recent blog a funder of collective impact said:

It’s a testament to the stickiness of the ideas behind collective impact that three years in, many people…remain pretty jazzed about the idea and its possibilities—but also deeply unsure about what exactly it is…

The question that Esther Dyson and Wellthcare have to answer is how we make health creation a sticky idea, something that will jazz people enough to experiment. In 2014, Wellthcare will be profiling initiatives that create health – the ‘Wellth Creators’, as we’re set to call them. We’ve had two to date, Jersey Post and GeriJoy. We’ll also be publishing a Manifesto that sets the agenda to experiment in the 80%. To paraphrase Nancy Adler’s writing, it’s too early to provide an explicit formula for how to create health but it’s not too early to start experimenting. Indeed, it might be getting too late.

I understand your 'drift'. However, to say that prevention doesn't work is nonsense. Try telling Africans that sleeping under mosquito nets or using condoms aren't great prophylactic behaviours. If we want to propagate Wellthcare globally, we really need to move beyond an Anglo-Saxon mindset. Indeed, Asian cultures have been engaged in Wellth creation activities for centuries.

Pritpal S Tamber

31/1/2014 10:48:56 am

Dear Clive,

That's an excellent point. When I was thinking about 'prevention' I was thinking of the behavioural stuff that's needed to ward off lifestyle related chronic conditions. You're absolutely right that for many acute and infectious conditions prevention works very well. Thanks for pointing that out.

I'd love to hear examples of Wellth creation in Asian cultures. Can you share some examples so I may profile them for the site?

Btw, what did you mean by my 'drift'?

Pritpal

Clive Pinder

31/1/2014 10:39:50 pm

'Get your drift' is a colloquialism for 'understand the point you are making'. As for behaviours of Wellthcare creation I am thinking of things like following the philosophy of Feng Shui or Buddhism. As for the ultimate lifestyle for creating Wellth, I always thought Epicureanism was a good 'direction of travel', he says writing from the beach house on Zanzibar :) Actually, I think there are many approaches to life that were 'imagined' to create Wellth....many philosophies and religions would claim that the creation of Wellth is their ultimate purpose? As you explore this idea, it will be fascinating to see how you avoid dogma which has been the tendency of 'modern' medicine....as in "we know what's best for you".

Pritpal S Tamber

2/2/2014 02:38:55 pm

Dear Clive,

Helpful thoughts, as always.

I think your dogma point is an important one. I believe the health care professions and industry has created, perpetuated and relished in an information asymmetry that has protected their market. It has served them well to date but I think there are two reasons why it's now being eroded.

Firstly, (some) people have started to learn more through the democratisation of information made possible by the Internet. And secondly, it's simply the case that we don't 'know' what works when it comes to preventing the onset or escalation of chronic diseases.

My sense is that these two forces will erode certain areas of the profession/industry and we'll see newer voices entering the fray.

Do you share my optimism?

P

Clive

2/2/2014 10:07:52 pm

I agree....although I'm not sure that the pace of change will,be fast enough. I wonder if the medical educational and training establishment is a facilitator or blocker in the democratisation of healthcare?

Pritpal S Tamber

3/2/2014 06:56:15 am

My personal view - for some time - been that the medical professions and industry are in denial of their true value as brilliantly evidenced in this recent blog by Richard Smith:

I think we have covered this issue in a previous chain. I'm not sure the endless fascination and homage to research is helpful. Actually I think it's part of the dogma and smokescreen that clinicians hide behind to protect their domain. With the exception of clinical trials to make sure drugs aren't doing more harm than good, I think most of medical research is like international aid.....a self-serving industry more concerned with promoting the interests of clinicians than the market they serve.